Windermere Rest Home

Profile & contact details

Premises details
Premises nameWindermere Rest Home
Address 10 Thornton Road Cambridge 3434
Total beds21
Service typesRest home care
Certification/licence details
Certification/licence nameWindermere Rest Home 2015 Limited - Windermere Rest Home
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence04 September 2019
Certification period36 months
Provider details
Provider nameWindermere Rest Home 2015 Limited
Street address 10 Thornton Road Cambridge 3434
Post address

Progress on issues from the last audit

What’s on this page?

This rest home has been audited against the Health and Disability Services Standards. During the last audit, the auditors identified some areas for improvement.

Issues from their last audit are listed in the corrective actions table below, along with the action required to fix the issue, its risk level, and whether or not the issue has been reported as fixed.

A guide to the table is available below.

Details of corrective actions

Date of last audit: 24 June 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.The Infection control coordinator (RN) has not accessed training to support her in her role. Ensure the IC coordinator is provided with infection control training to ensure she is suitably qualified for the role. PA LowIn Progress
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Internal audits have a comprehensive action plan documented each month. These action plans are not signed off as actioned. (Examples include all internal audits for 2016 and internal audits for July, August and September 2015). Ensure that action plans are documented as followed-up and signed off, when actioned. PA LowIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Not all compulsory training has been provided over the last two years; examples include: chemical safety, management of challenging behaviour, restraint, infection control, culture/Treaty of Waitangi and food safety. Ensure a process is in place and implemented to ensure all staff are trained to care for residents. PA LowIn Progress
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.Two of five resident files sampled (including the rest home tracer) identified that these residents, who were non-weight bearing at the time the weights were due, and could not be weighed as there were no suitable scales. Ensure that equipment is provided to meet all assessed care needs. PA LowReporting Complete07/03/2017
Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.Two of five resident files sampled did not have the initial assessment and initial care plans documented within the required timeframes. Three of five resident files sampled did not document evidence of a three monthly review by the general practitioner. Ensure that the initial assessment and the initial care plan are documented within the required timeframes. Ensure there is documented evidence that the resident is reviewed by the general practitioner at least every three months. PA LowReporting Complete07/03/2017
Service providers responsible for medicine management are competent to perform the function for each stage they manage.i) A medication competency had not been completed by the registered nurse administering medication. ii) Six of six caregivers who are administering and checking insulin had not completed the required insulin competency. iii) Two of four caregivers who were completing the second check had not completed the second checker competency. i) Ensure that all staff administering or checking medication complete the required medication competencies. PA ModerateReporting Complete07/03/2017
The facilitation of safe self-administration of medicines by consumers where appropriate.Two residents who were self-administering their inhalers had not completed the required self-medication competency assessments. Ensure that all residents who are self-administering medication have completed the required competency assessments. PA LowReporting Complete07/03/2017
A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.i) Seven of ten resident files sampled did not evidence three monthly medication reviews by the general practitioner. ii) One of ten files sampled did not have indications for use charted for ‘as required’ medication. iii) Not all weekly mandatory medication checks had been completed. i) Ensure that medication reviews are completed at least three monthly. ii) Ensure that all ‘as required’ medication have indications for use charted. iii) Ensure that all mandatory medication checks are completed. PA ModerateReporting Complete07/03/2017
The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.Not all of the incident forms for March (five) and one of the four incidents for April, had an RN review or signature. Progress notes did not reflect the incident has been followed up. Ensure there is a process in place to ensure that incident forms document an RN review within an acceptable timeframe. PA LowReporting Complete07/03/2017
Consumers have a right to full and frank information and open disclosure from service providers.Of five resident related incident forms for March 2016 and four for April 2016, all five for March and one for April did not document that the family had been informed following an adverse event. Progress notes for these incident forms did not document if the family had been informed (link to 1.2.4.3 for registered nurse follow-up). Ensure that information provided to family and residents is documented following an adverse event. PA LowReporting Complete07/03/2017

Guide to table

Outcome required

The outcome required by the Health and Disability Services Standards.

Found at audit

The issue that was found when the rest home was audited.

Action required

The action necessary to fix the issue, as decided by the auditor.

Risk level

Whether the required outcome was partially attained (PA) or unattained (UA), and what the risk level of the issue is.

The outcome is partially attained when:

  • there is evidence that the rest home has the appropriate process in place, but not the required documentation
  • when the rest home has the required documentation, but is unable to show that the process is being implemented.

The outcome is unattained when the rest home cannot show that they have the needed processes, systems or structures in place.

The risk level is determined by two things: how likely the issue is to happen and how serious the consequences of it happening would be.

The risk levels are:

  • negligible – this issue requires no additional action or planning.
  • low – this issue requires a negotiated plan in order to fix the issue within a specified and agreed time frame, such as one year.
  • moderate – this issue requires a negotiated plan in order to fix the issue within a specific and agreed time frame, such as six months.
  • high – this issue requires a negotiated plan in order to fix the issue within one month or as agreed between the service and auditor.
  • critical – This issue requires immediate corrective action in order to fix the identified issue including documentation and sign off by the auditor within 24 hours to ensure consumer safety.

The risk level may be downgraded once the rest home reports the issue is fixed.

Action status

Whether the necessary action is still in progress or if it is complete, as reported by the rest home to the relevant district health board.

Date action reported complete

The date that the district health board was told the issue was fixed.

Audit reports

Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits which gives an overview of the auditing process and explains what the audit reports mean.

What’s on this page?

Audit reports for this rest home’s latest audits can be downloaded below.

Full audit reports are provided for audits processed and approved after 29 August 2013.  Note that the format for the full audit reports was streamlined from 16 December 2014.  Full audit reports between 29 August 2013 and 16 December 2014 are therefore in a different format. 

Prior to 29 August 2013, only audit summaries are available.

Both the recent full audit reports and previous audit summaries include:

  • an overview of the rest home’s performance, and
  • coloured indicators showing how well the rest home performed against the different aspects of the Health and Disability Services Standards.

Note: From November 2013, as rest homes are audited, any issues from their latest audit (the corrective actions required by the auditor) will appear on the rest home’s page. As the rest home completes the required actions, the status on the web site will update.

Audit reports

Audit date: 24 June 2016

Audit type:Certification Audit

Audit date: 15 July 2015

Audit type:Provisional Audit

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